“I want to stop fraud in Medicare home health services. But I don't want to punish everyone. I want to make sure good providers get paid. Some fraud happens in Los Angeles. I want the government to stop fraud before it pays money. I want honest providers to keep helping people. My bill will do these things. It will reset payments and protect the good providers.”
Official Congressional Record
Mr. President, I rise today to introduce the Medicare Home Health Payment Integrity and Protection Act. This legislation would strengthen the Medicare home health program by advancing two complementary goals: protecting the home health program from fraud and strengthening access to these important services for the Americans who need them. I have long been a strong supporter of home healthcare. In a home visit I made in one of my first years as a Senator, I saw firsthand the extraordinary difference that skilled nurses, therapists, and other home health professionals make in the lives of patients and their families. Every day, these dedicated caregivers enable millions of our Nation's most frail and vulnerable individuals to remain in the comfort, security, and privacy of their home, which is where they most want to be. Home healthcare not only improves patients' quality of life but also helps avoid unnecessary hospitalizations and nursing home admissions, producing substantial savings for Medicare, Medicaid, and families alike. For these reasons, we should be strengthening, not weakening, the Medicare home health program. Yet recent trends present a troubling paradox. Despite the rapid aging of our population, the number of traditional Medicare beneficiaries receiving home health services has declined in recent years, from approximately 3.3 million beneficiaries in 2019 to 2.7 million just 5 years later. At the same time, nearly everywhere in our country, the number of Medicare-certified home health agencies has also been dropping. According to the most recent report of MedPAC, which is the independent agency analyzing and advising Congress on Medicare, excluding California, more than 500 home health agencies closed between 2019 and 2024, a decline of 5 percent. The picture is dramatically different in California, however, where the number of Medicare home health agencies has doubled over the same time period. Nearly all of that growth has occurred in Los Angeles County. If that strikes you as strange, you are in good company. As MedPAC observed, many stakeholders, including the California State Auditor, have concluded that the unusual pattern of home health agency growth and use in Los Angeles County raises ``significant program integrity concerns.'' In plain language, that means fraud. MedPAC further noted that Los Angeles County has already been identified as a major hotspot for waste, fraud, and abuse in Medicare hospice services and that the dramatic increase in home health agencies in the same area raises further flags. The California State auditor reported that one office building housed the corporate offices of more than 100 hospice agencies and dozens of home health agencies--a striking example of how organized fraud can exploit weaknesses in Medicare hospice enrollment and oversight. The concentration of Medicare home health spending in Los Angeles County is its own issue. This can be seen by the lopsided spending generated there. Even though only 2 percent of the Nation's Medicare fee-for-service beneficiaries live in Los Angeles County, that 2 percent generates 9 percent of all Medicare fee-for-service home health expenditures in the entire Nation--roughly 4\1/2\ times the expected share. CMS is fully aware of the fraud problem in Los Angeles County and has responded aggressively. I commend the Agency for doing so. My legislation builds on those efforts by strengthening CMS's ability to stop fraudulent providers before they enter the Medicare Program, ending the ``pay and chase'' model. The bill accomplishes this goal by enhancing enrollment screening for owners and managers of agencies operating in objectively high-risk markets, requiring more rigorous oversight of new and high-risk providers through targeted surveys, strengthening oversight of accrediting organizations, and improving verification that Medicare beneficiaries actually received the services billed to the program. Further, the bill requires agencies in high-risk areas to provide documentation showing that they are legitimate businesses, such as proof of liability insurance. The bill also requires more frequent unannounced site visits for agencies that are new, have changed ownership, or are reactivating their billing privileges. Funding to support these efforts is also authorized. These reforms are designed to identify fraudulent providers early while allowing legitimate agencies to focus on delivering quality patient care. The consequences of fraud extend well beyond the communities in which it occurs. When billions of dollars are improperly siphoned from the Medicare home health program, the result can undermine the integrity of the payment system used to reimburse legitimate providers. Honest home health agencies--particularly those serving rural communities--already face rising labor costs, workforce shortages, and the challenges of providing care across large geographic areas. Inadequate reimbursement threatens their ability to continue serving the seniors who depend upon them. Protecting the integrity of the Medicare home health program therefore requires more than identifying and prosecuting fraud; it also requires ensuring that legitimate providers are reimbursed fairly for the medically necessary care they provide. This is the bill's second key objective. To accomplish this, my bill directs CMS to reset the home health base payment amount using 2020 rates, adjusted for inflation, before applying future payment updates. Resetting to 2020 is appropriate because it reflects the first year of the current payment methodology under the Patient-Driven Groupings Model and predates the fraud patterns that later emerged. The bill also addresses a calculation distortion in the current payment methodology and directs CMS to implement appropriate corrections going forward. This legislation strikes the right balance. It strengthens CMS's ability to prevent fraud before taxpayer dollars are lost, while ensuring that honest providers have the resources necessary to continue delivering high-quality care. It advances both program integrity and payment integrity, protects Medicare beneficiaries, safeguards taxpayer dollars, and helps preserve access to the home health services that allow millions of Americans to receive care safely and independently in their own homes. I want to note that these program integrity provisions align with those outlined in the Protecting Seniors and Stopping Fraudsters Act, introduced by Rep. Van Duyne in May. I look forward to working with her to move our bills forward as quickly as possible. I urge my colleagues to join me in supporting this important legislation.
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